System and method for clinical strategy for therapeutic pharmacies

ABSTRACT

A system and method of distributing pharmaceutical prescriptions within a network of pharmacies based on the review of prescription claim data and patient medical state to enable stratification of patients, wherein each pharmacy within the network has been established to handle one or more particular patient medical states.

CROSS REFERENCE TO RELATED APPLICATION

This application is a continuation patent application of U.S. patentapplication Ser. No. 13/932,689, filed on Jul. 1, 2013; which is acontinuation patent application of U.S. patent Ser. No. 12/773,567,filed on May 4, 2010 and issued on Jul. 2, 2013 as U.S. Pat. No.8,478,611; said application is a continuation patent application of U.S.patent application Ser. No. 11/542,898, filed on Oct. 4, 2006, andissued on May 4, 2010, as U.S. Pat. No. 7,711,583, which claims thebenefit under 35 U.S.C. §119(e) of U.S. Patent Application No.60/723,581, filed Oct. 5, 2005, each of which is hereby incorporated byreference herein in its entirety.

FIELD OF THE INVENTION

The present invention relates to a system and method for computeranalysis of a patient's medical records and prescription claims,suitable for stratifying the patient into therapeutic and wellnesscategories, wherein patient prescriptions may be routed to therapeuticpharmacies particularly established to resolve protocols and fillprescriptions based upon patient therapeutic and wellness categories.The invention relates to a system and method for integrating therapeuticand wellness categories with clinical scores to better manageprescription benefit services. Further, the invention relates to asystem and method for routing and filling prescriptions in a therapeuticpharmacy network to optimally balance prescription filling workloads.

BACKGROUND OF THE INVENTION

Heretofore, pharmaceutical dispensing, the business of dispensing apharmaceutical medication based upon a doctor's prescription, e.g.,general retail pharmacy sites, have been structured as stand-aloneoperations, wherein an individual pharmacy had the capacity to fill anddispense any number of medications to a patient. A pharmacist within theretail pharmacy has the general knowledge and experience to resolve anumber of discrepancies in the prescription, determine if the patienthad appropriate insurance coverage, and, as necessary, formulate anddispense the prescribed medication. The trend in retail pharmaceuticaloperations had been to establish many identical drug stores within anetwork of pharmacies, so that each pharmacy within the networkvirtually mirror imaged all the other stores within the chain. Eachpharmacy within the established chain of pharmacies is stocked withidentical prescriptive medications, over-the-counter and retailproducts, and staffed by licensed pharmacists capable of dispensing allFDA-approved medications. Such a network of pharmacies had an advantageto the operator thereof in retail establishments dispersed throughout ageographical region, wherein a patient would bring a prescription to thepharmacy counter of the local drug store and wait for a medicationrecently prescribed by her doctor to be dispensed. However, with theadvent of today's mail order pharmaceutical services, wherein aprescription may be transmitted to the pharmacy via electroniccommunications, e.g., telephone, the Internet, facsimile, etc., to acall-in center, dispatched to a pharmacy within a network for filling,and mailed to the patient, many of the considerations associated with a‘neighborhood pharmacy’ become less important. The neighborhoodpharmacy's concern with stocking a large variety of drugs to meetpatients' needs and delivering prescriptions to waiting patients are nolonger of paramount consideration. Other factors that will make a mailorder network of pharmacies more efficient and economic need to beconsidered.

SUMMARY OF THE INVENTION

The present invention relates to a system and method for computerimplemented analysis of patient medical records and/or prescriptionclaims to provide patient stratifications, therapeutic conditions andclinical score information, wherein the information is suitable forrouting prescriptions to specialized therapeutic pharmacies within anetwork of pharmacies for improving pharmaceutical services. Moreparticularly the invention relates to a method for routing apharmaceutical prescription to a therapeutic pharmacy within a networkof therapeutic pharmacies, wherein the method is suitable for selectinga therapeutic pharmacy for filling the prescription based upon patientmedical records and prescription claims, comprising the steps of:

-   -   a. means for receiving a pharmaceutical prescription for a        patient at a pharmacy intake center;    -   b. retrieving medical records and prescription claims for the        patient from an information warehouse;    -   c. analyzing the medical records and prescription claims to        stratify the patient into a disease category;    -   d. establishing a network of therapeutic pharmacies, wherein        each therapeutic pharmacy within the network is established in        accordance with a wellness category;    -   e. classifying the patient prescription to the patient wellness        category, and routing a pharmaceutical prescription to a        therapeutic pharmacy within a network; and    -   f. filling and dispensing the prescription to the patient.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is an illustration of a clinical approach of the method of thepresent invention to stratify patients into wellness groups;

FIG. 2 is an illustration of a categorization of individual therapeuticcenters within the network of therapeutic centers of the presentinvention to service disease groups;

FIG. 3 is an illustration of a method of making clinical decisions ofthe present invention;

FIGS. 4A and 4B are schematics of the system of the present inventionsuitable for practicing the clinical method of the present invention;

FIG. 5 illustrates a schematic of OWLb;

FIG. 6 illustrates work routed to individual therapeutic pharmacieswithin a network of therapeutic pharmacies;

FIG. 7 illustrates the work load of a particular pharmacy within thenetwork of pharmacies;

FIG. 8 is an illustration of a method of making clinical decisions ofthe present invention;

FIG. 9 is an illustration of a method of improving the dialog for makingclinical decisions of the present invention;

FIG. 10 is an illustration of a method of making clinical decisions ofthe present invention;

FIG. 11 is a diagram of a system suitable for practicing the clinicalmethod of the present invention;

FIG. 12 is a screen shot of a system of the present invention wherein alogin page is illustrated;

FIG. 13 is a screen shot of a system of the present invention wherein analert of a system's pharmacy routing capacity chart is illustrated;

FIG. 14 is a screen shot of a system of the present invention wherein arouting capacity chart of a particular pharmacy is illustrated;

FIG. 15 is a screen shot of a system of the present invention wherein arouting capacity chart of a particular pharmacy is illustrated;

FIG. 16 is a screen shot of a system of the present invention wherein apharmacy routing capacity rule confirmation may be requested;

FIG. 17 is a screen shot of a system of the present invention whereinrouting dimensions for sending the prescription to a suitable pharmacyis illustrated;

FIG. 18 is a screen shot of a system of the present invention wherein arule confirmation for routing a prescription to a particular pharmacy isillustrated;

FIG. 19 is a screen shot of a system of the present invention wherein apatient's general information and open prescription orders areillustrated;

FIG. 20 is a screen shot of a system of the present invention whereinanother patient's general information and open prescription orders areillustrated;

FIG. 21 is a screen shot of a system of the present invention wherein apatient's known medical conditions and directions for new medication maybe coded into the system; and

FIG. 22 is a screen shot of a system of the present invention wherein achart of a patient's open/unresolved prescription orders and medicationinformation are illustrated.

DETAILED DESCRIPTION OF THE INVENTION

The present invention is directed to a system and method forestablishing and operating a plurality of individual therapeuticpharmacies within a pharmaceutical network, wherein each therapeuticpharmacy has been established to fill and dispense prescriptivemedication associated with particular disease and disease states. In oneembodiment of the invention, members of a particular health insuranceplan may be classified into various states of wellness. FIG. 1 providesan illustration of four (4) possible classes of a state of wellness thatmay be utilized to segment members, e.g., well, acute, chronic andcomplex. The classification of ‘well’ may be associated with conditionsthat are least severe, e.g., wrinkles, baldness, impotence, etc., whilean ‘acute’ state may be associated with colds and flu, strep throat, earinfection, headaches, sprains, etc. A more serious state of ‘chronic’may be associated with heart disease, diabetes, arthritis, high bloodpressure, high cholesterol, dementia, back pain, etc., while ‘complex’conditions may be associated with life threatening conditions such asheart failure, diabetes, cancer, AIDS, metabolic syndrome, etc. Inanother embodiment of the invention, members of a particular healthinsurance plan may be classified into various disease conditions. FIG. 2provides an illustration of such a classification, wherein the diseasemay be partitioned as neurology/psychiatry, pulmonary, cardiovascular,diabetes, gastroenterology, oncology/hematology, rare diseases, etc. Thefigure provides an illustration of a further classification of eachaforementioned disease state, wherein the classification of diabetes maycontain the conditions of Type I, Type II, pediatric, metabolicsyndrome, complex, etc. Accordingly, within a network of therapeuticpharmacies, wherein a plurality of individual therapeutic pharmaciesoperate to fill and dispense prescriptions, one or more of theindividual pharmacies may be strategically established based on a stateof wellness or for one or more particular diseases. Pharmacist withineach individual therapeutic pharmacy may be specifically trained toprovide services for particular states of wellness or disease categoriesassociated with the individual therapeutic pharmacy within the networkof pharmacies. To determine whether a patient is complying with theadministration of medication, or if there are possibilities of utilizingalternative, less costly medications, a clinical score may be generatedby an analysis of patient claim history, formulary rules, and medicalrecords. For example, a high clinical score, e.g., 10, may beinterpreted as high possibility of reducing patient cost by prescribingalternative medications, e.g., generics, while a low clinical score,e.g., 2, may be interpreted as low possibility of reducing patient costsand that the patient is efficiently utilizing all formulary advantagesassociated with a particular health insurance plan.

FIG. 3 illustrates a typical patient-physician-pharmacist relationshipembodiment of the present invention. In accordance with the figure, thepatient has been diagnosed with several medical conditions, includingdiabetes, high blood pressure, high cholesterol, migraines, coronarydisease, and back pain. The attending physician has diagnosed theconditions and may prescribe one or more medications for treatment. Uponreceiving a prescription, the system of the present invention willprovide ‘clinical decision support’ comprising reviewing ‘best practicerules’ and establishing ‘model and analytics’ to stratify the patient inone or more wellness or disease categories. The ‘best practice rules’comprise determining whether there is appropriate coverage under ahealth insurance plan for the prescription, within the patient'sformulary, a drug utilization review, and potential adverse effect withother medications. The ‘model and analytics’ comprise profiling thepatient-physician relationship to determine if the physician prescribesadditional medication for the patient, whether financial opportunitiesexist to reduce plan and patient costs, the clinical appropriateness ofutilizing the medication for the particular ailment, and stratificationof the patient into one or more wellness and/or disease categories.

FIG. 4 is a schematic of the system of the present invention, wherein aprescription (010) may be provided by a prescriber, e.g., physician, toa patient, wherein the prescription is directed to medication suitablefor relieving an ailment or disease suffered by the patient. The patientmay submit the prescription to Prescription Receiving unit (100) forfilling and dispensing to the patient. The Prescription Receiving unitis in electronic communication with a Patient On-line AuthoritativeRecord unit (200) (POLAR) and request necessary information about thepatient prior to processing the prescription. Similarly, POLAR, throughelectronic connections with a Patient Stratification unit (300) and aClinical Score unit (400), is in electronic communication with anInformation Warehouse database (500), suitable for receiving, storingand transmitting patient medical record and/or prescription claiminformation. POLAR will contain data files for all patientsparticipating in a health insurance, prescription plan. InformationWarehouse database may be continually updated with new medical recordsand prescription claims as they become available. The information mayinclude patient identifiers and data, e.g., names, addresses, patientidentifiers, insurance providers, co-pay information, formularyinformation, prescription order histories, medical records, etc. Theclinical scoring and stratification process will continually execute andupdate to determine a patient's stratification/wellness category andclinical score, which is subsequently stored in POLAR for use byPrescription Receiving or display by a user, e.g., pharmacist or claimsrepresentative, and for making a therapeutic routing decisions. AfterPOLAR collects data regarding patient stratification and clinical score,it electronically communicated with Formulary Rules database (600) todetermine if the prescription is within the patient's insurancecoverage, formulary and rules. Formulary Rules is also capable ofperforming drug utilization reviews and screening for potential adverseeffects of the prescribed medication with other medications the patientmay be administering. After POLAR has collected the necessary datarequired to fill the prescription, it notes any unresolved protocolsfrom the Information Warehouse or Formulary Rules is inconsistent withthe prescription, e.g., lack of insurance coverage, medication outsideof the formulary, potential adverse effects with other medications, etc.and transmits the information to POLAR which relays the collectedinformation to Prescription Receiving for merging with the prescription.Afterwards, the merged prescription and patient information iselectronically forwarded to a Optimal Workflow and Load Balancing unit(700) (OWLb), wherein OWLb examines the POLAR data to determine theoptimal Therapeutic Pharmacy (800) and pharmacist (900) within thatTherapeutic Pharmacy suitable for handling the prescription order.Thereafter, the order will be assigned to the Pharmacist andelectronically appear on her computer task screen. If POLAR has notedany unresolved protocols, the Pharmacist may transmit the prescriptionorder to an Integrated Contact Management unit (1000) (ICM) forresolution, wherein ICM will communicate with POLAR to gather additionalpatient stratification and clinical score information the Pharmacist mayneed for display on the pharmacist's computer task screen. Thisadditional data is may be used to assist the Pharmacist in resolvingopen protocols on that patient's order and allow the order to eventuallybe filled and dispensed.

Prescription Receiving (100)

In accordance with one embodiment of the present invention,pharmaceutical prescriptions may be received at a Prescription Receiving(010) for a network of therapeutic pharmacies, wherein individualtherapeutic centers, i.e., therapeutic pharmacies, within the networkare established based on patient stratifications and/or therapeuticconditions. The prescription (010) may be received by PrescriptionReceiving (100), wherein the prescription contains patientidentification information, physician and prescriber information, aswell as type of medication, and medication quantity and concentration,etc. Generally, the prescription may be received in electronic form, butif necessary, a hard-copy prescription may be scanned or converted toelectronic form by conventional means and fed into the PrescriptionReceiving unit of the present invention. Prescription Receiving mayresolve administrative protocols, e.g., patient enrollment andeligibility, prior to processing the prescription in the system of thepresent invention. Upon resolution of any administrative protocols andconversion into an electronic form, if necessary, the prescription maybe fed into the system for filling and dispensing.

Patient On-Line Authoritative Records (POLAR) (200)

POLAR, is a data store, which maintains information relevant at thepatient level. This includes Patient Stratification and Clinical Scoredata that is used by OWLb for determining optimal work assignments anddisplaying in Integrated Contact Management. POLAR may be periodicallyupdated by the Information Warehouse to reflect changes in the clinicalscores and patient stratification information. POLAR is capable ofcreating an individual artificially generated number (AGN) which is aunique person identifier that enables the organization to track aperson's demographic, clinical and communication history as well asfinancial activity at the individual level. The individual AGN may beassigned in a background process when data is moved to the InformationWarehouse. POLAR receives data from Patient Stratification (300) andClinical Scores (400), and analyzes the data to assign an AGN suitablefor routing a prescription to a selected therapeutic pharmacy within thenetwork of therapeutic pharmacies particularly established to providespecialized pharmaceutical care to a patient of a correlating wellnesscategory. The AGN for a patient is transmitted to an Optimal Workflowand Load Balancing (OWLb) system (700) where it is utilized. POLAR maycontinuously receive data from Patient Stratification and Clinical Score(400) for generation of the AGN.

POLAR stores and updates data from multiple sources and supports currentpostal addresses and e-mail addresses and telephone numbers forpatients, as well as date of birth, deceased status, gender, demographicand geographic information, medical conditions, drug allergies, HIPAAprivacy consent and authorizations. POLAR provides a data qualitydashboard to help determine the integrity of the data, e.g., confirmsaccuracy of data, provides tracking analyses detecting potentialinconsistencies in data patterns (system errors, incomplete, orirrelevant data), and improves identification and targetingopportunities. POLAR populates IW for decision support analyses andreporting. POLAR provides a wide variety of software applications withthe core objective to increase data quality and content for clinicaldata used by DUR, Home Delivery Pharmacies, Customer Service, andInternet applications. These various software applications interfacewith two main clinical data stores: Patient Profile VSAM files and theNRXPRF Idiosyncrasy table. The Patient Profile VSAM files are thecentral clinical repository for all ICD-9 codes for Medical Conditionsand NDC codes for Drug Allergies. The Patient Profile VSAM files areupdated daily by Home Delivery Pharmacy applications during prescriptionprocessing, Customer Service application systems, Internet, HealthAssessment Questionnaires responses from our Members, and Client feeds.All clinical information contained in both main data stores may be usedby DUR during prescription processing. There are a wide variety of POLARsoftware applications that interface with these data stores, internaloperational system areas, external vendors, and clients. POLAR softwareapplications encompass development of periodic patient profile ICD-9 orNDC files from external vendors, internal departments, and client feeds.Development of a centralized repository for clinical codes anddescriptions that are used on various Home Service Delivery and CustomerService screens. These tables control what descriptions, options, codes,etc. are displayed on various customer service type screens as well aswhat codes should be passed to POLAR. POLAR is capable of processingmandatory communications, such as Health Assessment Questionnaires,Notice of Privacy, Authorization, and Consent forms. The system managesthe entire solicitation life cycle for mandatory communications from theinitial entrance into the system, releasing records to internal orexternal vendors for solicitation distribution, vendor feedbackconfirmations, and response tracking. The new POLAR Communication Systemalso has been designed to allow substantial depth for custom fulfillmentneeds. POLAR stores current and historic address and phone numberinformation for individuals. Additionally, the address databases may bestructured to store permanent and current address and phone numberinformation. All addresses in POLAR may be processed through CODE-1 datacleansing, to ensure that POLAR has deliverable contact information. Inaddition to existing book of business address cleansing efforts, POLAReither may receive address and phone number updates via customerservice, MMRx, Internet applications, health management systems, managedcare operations, client systems/projects, InterDirect—vendor addresscleansing/lookups, Health Assessment Questionnaires, etc. In addition to‘pushing’ address and phone number information to POLAR, many of theoperational systems listed above use POLAR to ‘pull’ the most currentdemographic information for an individual upon demand. Additionally, thedemographic information retained in POLAR is used in developing businessstrategies for increasing the overall quality of our health careproducts and person-centric services. POLAR stores current and historicpreference information for individuals in its databases. Currently,preference information encompasses an individual's desire to eitherOpt-Out or Opt-In to a health product or service, refill reminder and‘never ask’ preferences, as well as E-Health preferences. Futurecapability includes the ability to retain how and when an individualprefers to be contacted (i.e., mail, E-Mail, telephone, or facsimiles)as well as prescription bottle types, lifestyle and behavioral factors.

In addition to ‘pushing’ preference information to POLAR, many of theoperational systems listed above use POLAR to ‘pull’ the most currentpreference information for an individual upon demand. Additionally, thepreference information retained in POLAR is used in developing businessstrategies for Medco Health and increasing the overall quality of ourhealth care products and person-centric services. POLAR Correction andDistribution Workstation (CDW) is an operational based capability thatmay be used to process member information updates on POLAR data stores.The system manages information updates for SSN to non-SSN transfers,Patient Profile zero AGN corrections, and AGN Over/Under matchcorrections. The POLAR Patient Profiles contains allergy and medicalconditions for our members. This information is used by DUR during drugutilization review to ensure there are no adverse drug interactions.Data in the patient profiles is stored at the Individual AGN level,along with various member information (member number, carrier, date ofbirth, etc.). On occasion, the Individual AGN is unknown at the point ofupdating the profile, and an attempt must be made to later derive onefor the profile record to be used. These ‘zero AGN’ records are read infrom the patient profiles on a nightly basis and processed via the CDWfront end. POLAR Patient Profiles contains allergy and medicalconditions for our members. This information is used by DUR during drugutilization review to ensure there are no adverse drug interactions.Data in the patient profiles is stored at the Individual AGN level,along with various member information (member number, carrier, date ofbirth, etc.). On occasion, the Individual AGN is assigned incorrectly(either the same AGN is assigned to multiple different people, ormultiple different AGNs are assigned to the same person). Theseover/under match records are identified by eligibility and provided toall areas of the company. The CDW user takes this information andperforms the necessary updates to the core POLAR data stores. A fullaudit trail of the correction for each AGN and the data store where theinformation was modified is stored within the CDW.

Patient Stratification (300)

Patient Stratification is a unit within the system of the presentinventions suitable for computer analyses of patient medical record andprescription claim information contained in the Information Warehouse(200) to determine the potential for utilizing the method and system ofthe present invention, wherein the database contains sufficientinformation to perform analyses. If sufficient medical record andprescription claim information is available to perform a patientanalysis, wherein the patient will be stratified into one or morewellness categories, e.g., well, acute, chronic, complex, etc. Eachwellness category may be further defined, for example, by the pastmedications prescribed to a patient, illnesses, and diseases states. Forexample, FIG. 2 illustrates one embodiment of the invention ofstratifying patients into wellness categories, based upon diseasestates, into a plurality of wellness categories, wherein less seriousdiseases may be defined as well and acute, and more serious diseases maybe defined as chronic and/or complex. For example, FIG. 3 illustratesseveral disease state defined in accordance with established medicaldisease categories, e.g., neurology/psychiatry, pulmonary,cardiovascular, diabetes, gastroenterology, oncology/hematology, raredisease, etc., and patients may be placed into one or more diseasestates based upon the patient's current medical diagnosis. While thedisease states mentioned herein are examples of methods of classifyingpatients, other methods and categories will become apparent to thoseskilled in the art. Nevertheless, the individual therapeutic pharmaciesof the network of therapeutic pharmacies of the invention will besegmented based upon the categorization utilized for patientstratification, wherein the individual pharmacies will be established tofill and dispense prescriptions for one or more categories of diseases.Patient stratification results may be available for transmittal to andstorage in POLAR.

Clinical Score (400)

Clinical Score is a unit of the invention wherein a numerical valueassigned to a patient based upon the quality of pharmaceutical servicesreceived, wherein a low score represents very good services and a highscore represents poor services. For example, if a patient prescriptionclaims history reveals that the patient suffers from wrinkles, baldness,impotence, utilizes contraceptives and/or is vitamin deficient, inaccordance with the method, the patient's score may be established asWell. If the patient prescription claims history reveals that thepatient suffers from occasional colds and flu, strep throat, earinfection, headaches and sprains, the patient may be scored as Acute.Further, if the patient prescription claims history reveals that thepatient suffers from heart disease, diabetes, arthritis, high bloodpressure, high cholesterol, dementia and/or back pain, the patient maybe scored as Chronic. If the patient claims history determines that thepatient displays multiple chronic conditions such as heart failure anddiabetes, cancer, AIDS and/or metabolic syndrome, the patient may bescored as Complex. Clinical Score modeling may take the form of manyconventional methods. In one embodiment of the invention, for eachcomplex patient, calculate the points for each of the 4 clinical indexesbelow. Add up all of the scores for a given patient and retain a totalClinical Score. Assign a reason code or explanation for each clinicalindex which can be passed to POLAR with the total clinical score.

Clinical Care Opportunities: a) Polypharmacy Number of Medications

Evaluate each patient's paid pharmacy claims history for the last 180days to determine the number of unique drugs (HICL) listed.Score: Provide 1 point for each unique drug (HICL) listed in thepatient's paid claim history for the last 180 days. Sum the number ofpoints (to a maximum of 30) for a total medication score. Reason code:List the number of drugs found in the last 180 days, e.g., patienttaking “X” drugs in the last 180 days.

b) Concurrent Drug Utilization Review: Home Delivery (HD) CDUR

Evaluate each patient's paid pharmacy claims history for the last 180days for the listed CDUR alert protocols with the specific resolutioncodes. See Appendix B.1 for Home Delivery CDUR protocols, resolutioncodes and points.Score: For each patient, count the points assigned to each selected HDCDUR Protocol with specific Resolution codes, e.g., for protocol Seniors—excessive daily dose (SURHD), resolution code dispense as written—nocall (DAWNC)—2 pts., Seniors drug disease (SURMC), resolution codedispense as written, no contact w/ MD spec time (DAWNC)—2 pts.=4 and addthem together with the Retail CDUR points for a total CDUR score for thepatient.Reason code: For each patient, select the most current 3 HD CDURprotocols that have the resolution codes with the highest point valuesassigned to each, e.g., Seniors —excessive daily dose (SURHD),resolution code dispense as written—no call (DAWNC)—2 pts.; Seniors drugdisease (SURMC), resolution code dispense as written, no contact w/ MDspec time (DAWNC)—2 pts. Display the resolution date, protocols andresolution codes in English & the applicable drug names for therespective protocols.

Retail CDUR

For each patient, count the 2 points assigned to each selected RetailCDUR with an 02 override code and add them together for a total RetailCDUR score. Then add them to the HD CDUR score for a total CDUR scorefor the patient.

c) Retrospective Drug Utilization Review & RationalMed: RDUR, TherapyOptimization & RationalMed: Therapy Optimization and Omission of Therapy

Evaluate each patient's paid pharmacy claims history for the last 180days for the listed therapy optimization and omission of therapyenhanced rule (SDI and SCI) alerts fired. Score: Each selected RDURalert fired receives 2 pts. Add up all points for total RDUR-RM scorefor the patientReason code: Select the 2 most current alerts fired e.g., Treatment ofstable angina (SDI 002) & ACE inhibitor or ARB for the prevention &treatment of diabetic nephropathy (SDI 004). Display the date the rulewas triggered, drug(s) name/NDC (in English) and the letter text fromthe physician letter template.Source: IRHM_Proddb_v.protocol_event; Protocol Management Decision(PMD), tables in IW “Event” RDUR files updated quarterly; RationalMedfiles updated monthly

d) Late to Fill:

Persistency—Length of continuous medicationNon-persistence—A late-to-refill that exceeds 60 days from the end ofthe last fill and is still present at the current run date.Discontinuance of persistency flag—Turn off the patient's persistencyflag for a specific drug chapter if (latest fill date+dayssupply+180−1)<current run date then patient is discontinued for aparticular therapy

Priority

1. Anti-arrhythmic agents: 4.12. Anti-hypertensive therapy: 4.53. Diabetes: Insulin therapy 7.5.1; oral hypoglycemic agents 7.5.24. Lipid-lowering agents: 4.65. Anti-platelet drugs: 4.4.2Late to Fill detail.Score: If non-persistent with any of the above drug chapters, assign aYes=5 pts.; If persistent with any of the drug chapters, assign a No=0pt.A patient can have 0-25 points depending on the number of Yes answers.Add all of the Yes answers for a total persistency score for thepatient.Discontinuance of therapy will be assigned a score of 0 points for thepurpose of calculating the total persistency score.For IW, the requirement for reporting will be to store the score for all5 drug chapters for each patient with a way of differentiating betweenthose who are persistent and those that have dropped off (0 points).Reason code: Select the most current 2 drug chapters that arenon-persistent e.g., diabetes 7.5.2 & antihypertensive therapy 4.5, andlist each of them with the explanation “Late to refill->60 days”, theappropriate drug(s)/NDC (in English) and run-out date (latest filldate+days supply+60-1). If more than 2 are non-persistent, use priorityas listed above. Number 1 has the highest priority and should beselected first and so on.

Financial Savings Opportunity Indexes

Use existing programs, their business rules and drug lists:

New Prescriptions

Co-pay and client savings opportunities will be based on existingManaged Care programs, using the Managed Care system and interventionsmethodology.An interface between ICM and Managed Care system, using screen-scrapetechnology, will provide the pharmacist with access to and detail on thefinancial opportunities available through the Managed Care programs. Thepharmacist will view and resolve the opportunities in the Managed Caresystem. Programs include:

-   -   Therapeutic interchange;        -   Non-preferred to preferred brand name drugs; and        -   Brand name drugs to generics;    -   Coverage Management;        -   Traditional Prior Authorization;        -   Step Therapy; and        -   Dose Optimization-Coverage;    -   Formulary Coverage Review (FCR)

Existing Prescriptions

-   -   Therapeutic Interchange;        -   Non-preferred to preferred brand name drugs; and        -   Brand name drugs to generics    -   Retail to Mail Conversion        -   “Home Delivery Advantage” Program    -   Therapeutic Interchange;        -   Non-preferred to preferred brand name drugs; and        -   Brand name drugs to generics            The Managed Care interface will provide the pharmacist with            detailed information on patient specific ‘ProActive’            financial opportunities. The pharmacist will view and            resolve the opportunities in the Managed Care system.

Home Delivery Advantage Retail to Mail Conversion Opportunities

Identify (at a drug specific [NDC] level) any retail prescriptions fortargeted maintenance drugs for the most current 3 months. Using currentpricing, eliminate opportunities that generate a negative clientsavings.Use Home Delivery Advantage business rules to identify the retail tomail conversion opportunities. A Patient Stratification opportunity forconversion from retail to mail would be where there has been no activityrelated to a channel shift from retail to mail e.g., with no response toa letter or HD Advantage decline outcome code.Source: This could include new patients, new patient/drug combinations,or updates to existing opportunities. The load file should be unique onGroup Operational ID (Group)+Client Membership ID (MemberNumber)+Relationship Code (Relationship)+Person Number (PersonNumber)+Mail NDC (NDC). Each opportunity includes a CORE Opportunity IDand CORE Opportunity Sequence Number.

Information Warehouse (IW) (500)

Information Warehouse is a database comprises patient medical record andprescription claim information. The database, continually updated withnew patient information, may contain patient information of previousmedical record and prescription claims compiled over a chosen period oftime and may include medical records, prescription plan, claims history,home delivery purchased, retail purchased, refill history, prescriptioncosts, prescription co-pay history, etc., wherein the information issuitable for determining Patient Stratification (300) and Clinical Score(400). Information Warehouse is charged with providing clinical andfinancial business information that encompasses the claims dataavailable. Information Warehouse is a data repository that supportsclinical, financial analysis and reporting of claim activity. It issuitable for storing about 36 months of internal and external claimshistory and client, patient, provider (prescriber and pharmacy) and drugdata related to the adjudication of those claims. Aside from makingclaims history available, the Information Warehouse provides a uniquepatient identification feature. The patient identification process usesthird-party data cleansing software to identify an individual across thesystem. The process assigns a unique patient identifier, regardless ofwhether she is eligible in multiple groups or have had interruptedcoverage. It is this capability, along with the capability of analyzingmedication usage and costs over time, that make the warehouse theoptimum source of data for targeting programs developed in the company.Information Warehouse responsibilities include the identification,definition, modeling, and sourcing of all data that are stored therein.Architecturally, the Information Warehouse utilizes specializedMassively Parallel Processing (MPP) hardware and system software thatdecomposes database requests into smaller sub-units that can beprocessed in parallel. This architecture enables the rapid processing oflarge volumes of data with elapsed times several orders of magnitudeless than would otherwise be possible.

The ‘claim subject area’ of IW contains facts about the claims submittedby client-members in conjunction with the dispensing of medicalproducts. The main data category within this subject area is a set ofphysical claim tables, organized by client, which house claims data.Each claim has relationships to the reference data in each of the othersubject areas. For example, a claim will point to the relevantprescriber in a ‘provider subject area table’. Similarly, a claim willpoint to the relevant product, group and member in the ‘drug, client andpatient subject areas’, respectively. As a result, the amount ofreference data kept in the central fact table may be reduced. Thissubject area includes numerous attributes related to the claim type,prescription, pricing, dispensing, refills, cost components,adjudication, adjustments, co-pay, deductible, etc.

The ‘client subject area’ contains reference data about the clientorganizations that currently use or recently used the pharmacy benefitmanagement services. The main data categories within this subject areaare the multi-level operational units comprising a client organization(client organizational ids, carriers, contracts, groups, benefit groupsand related groups) and the high-level products and services that aclient has contracted for (e.g., disease management programs). Each typeof relationship that links the different client operational levels isshown as a separate hierarchy (e.g., client sales hierarchy, clientbilling hierarchy, etc.). This client subject area includes variousattributes that characterize a client's status, organizationalclassification, eligibility rules and special processing requirements.It also identifies the claim table where a client's claims aremaintained.

The Drug Subject Area contains reference data pertaining topharmaceutical and other products that have been approved for sale bythe Food and Drug Administration (FDA). The main data categories withinthis subject area are the medical products from manufacturers, productpricing and formularies, and their organization into therapeuticchapters and sub-chapters. Medical products include both drugs andcertain non-drug products, such as medical supplies. A drug product hasnumerous physical attributes, such as strength, dosage form,administration route and package size. A drug product also hasidentification attributes, such as numeric codes and names. Drugs areclassified according to criteria that reflect the generic formulation,generic market status and therapeutic class. This subject area includesthe classification of drugs, their therapeutic properties and uses, andthe classification of diseases and medical conditions.

The ‘patient subject area’ contains reference data about the active andretired employees of clients who receive pharmacy benefits. The maincategories within this subject area are memberships, members andpatients. Membership identifies the members covered under a particularbenefit plan. A member is an individual covered under a membership,including the originating subscriber and any dependents to whichbenefits have been assigned. A patient is an individual who may receivebenefits under one or more plans regardless of the individual's carrier,contract or group identification. This patient subject area includesmembership and member identifiers, coverage attributes and memberattribute data. It also identifies a member's primary care provider andmembers within each carrier for whom claims have been submitted.

The ‘provider subject area’ contains reference data about the individualpractitioners and provider organizations involved in providing healthcare services of interest, e.g., writing prescriptions for anddispensing drugs. The main data categories within this subject area arethe individual practitioners authorized to write prescriptions (alsoknown as prescribers) and the pharmacies that process and fill theprescriptions. Practitioners may be classified by type of medicalpractice and medical specialty. Provider organizations may be classifiedby type of pharmacy, organizational status (pharmacy or pharmacyorganization) and organizational affiliation (chain, franchise orunaffiliated). This provider subject area includes the variousidentifiers used to identify providers, as well as provider attributedata, some common to both pharmacies and practitioners, such as name andaddress, and some specific to one type or the other.

Formulary Rules (600)

Utilization Management shall implement a set of rules that enforcecompliance with the SPCR for a particular therapy. In general the SPCRshall determine the timeline, type of intervention and skill setrequired for a type of intervention as shown in the example in the tablebelow:

Call Call Call Rx Purpose and Name From To Status Timing Call ContentInitial RN/ Patient New Upon Delivery/Admin Patient PCR receiptLogistics Storage require- ments Offer to counsel Schedule InitialPatient Adminis- tration call, if necessary Send starter packet InitialRPh/ Patient New Within 2 Storage/Adminis- Patient Nurse days posttration Adminis- manifest ADRs tration date Compliance with drugs andmoni- toring Follow-up RPh/ Patient Refills & 3, 7, and 11Storage/Adminis- Patient Nurse Renewals weeks post tration therapy ADRsinitiation Compliance with drugs and moni- toring Follow up Therapy PCRPatient Refills & Upon refill Delivery/Admin Confirma- Renewals orrenewal Logistics tion Call- request Storage require- Patient mentsOffer to counsel Schedule Patient Follow-up Call, if necessary Refill/PCR Patient Refills & 7 days prior Delivery/Admin Renew Renewals to nextrefill Logistics Patient (wk 23, 35) Screening Offer to counsel SchedulePatient Follow-up Call, if necessary

Prior Authorization Rules confirms that the incoming prescription isconsistent with plan coverage provisions. At times it may be necessaryto contact the prescriber to obtain additional information to confirmcoverage. In the event the prescription is not covered by the patient'splan, a Patient Care Representative (PCR) will contact the patient andthe pharmacist will abort the prescription.

DUR Rules compares the incoming prescription with the patient'sprescription history to detect potential health and safety issues andinteractions such as, drug to drug, drug to allergy, drug to disease,dosing and over-utilization. In the event a potential health and safetyissue is detected by the DUR rules engine an alert is fired. Thepharmacist or physician may override the alert, modify the prescriptionor abort the prescription. In the event the prescription is changed ormodified the patient is notified.

Managed Care Rules identifies potential cost effective and clinicallyequivalent product opportunities (i.e., generic or preferred products).The opportunity is presented to the physician and if the physicianchanges the prescription to the recommended product, the pharmacist willchange the prescription and the Patient Care Representative will notifythe patient that the prescription was changed.

Prescription Fill Rules ensure that for specific a therapy regimen mayrequire specific clinical information each time a prescription isrefilled. In some cases it may be necessary to contact either thephysician or the patient to obtain the required information. The rulesthat process this information may modify the therapy regimen. Examplesof the type of rules that may take place are:

First Fill Rules

Aside from making sure all required patient information is present inthe system, each CoE may have unique information requirements. Forexample, for Hepatitis C an important determination is the patient'sgenotype as well as the timing of the patient's therapy. Other rulesdeal with patient training, delivering the drugs and additional care asper SPCR (Standard Procedure & Counseling Resource). Some rules mayrequire a contact with the physician or patient.

Second/Third Fill Rules

This time around the rules deal with a refill. If no active refillsremain, the pharmacist must contact the physician for refillauthorization. In addition, DUR, compliance issues, therapy relatedquestions and need for additional patient support may trigger aphysician or patient contact.

Fourth Fill Rules

The fourth fill (technically a refill) is similar to prior fill rules,except that the patient's viral load (in conjunction with genotypeinformation) is taken into account and specific SPCR instructions forthe fourth month are consulted and followed-up.

Bundle Contacts Rules

Bundling rules shall create queries that shall be executed against thecontact database to group contacts that are consistent with the role andCenter of Excellence (CoE) of the user that requested a bundle.

Prioritize Contacts Rules

Prioritize contacts shall provide the rules to determine which contactto first resolve. The rules prioritize contact based on time contact wasoutstanding and clinical and financial benefit.

Route Contacts & Balance Workload Rules

Workflow management shall manage skill set routing and load balancingrules that monitor the workload associated with a requesting skill setand if the resource is under utilized than the query for bundling willbe modified to route the bundle to a compatible skill set.

Optimal Workflow and Load Balancing (OWLb) (700)

Referring to FIG. 5, OWLb is responsible for determining the optimalassignment of a patient's order to a person. OWLb takes a variant ofperspectives into account when determining the optimal assignment. OWLbis suitable for receiving incoming prescriptions from prescriptionintake (100) and AGN data from POLAR, may utilize established criteria,rules and AGN data to prioritize and bundle prescriptions, and route theprescriptions to a therapeutic pharmacy particularly established, withinthe network of therapeutic pharmacies, to provide specialized servicesin accordance with AGN data, intervention type, pharmacy work load,prescription dates, etc. For example, if two or more therapeuticpharmacies within the network are suitable for filling a prescriptioncorrelating to particular AGN data, OWLb may select the pharmacy havingthe least workload when routing the prescription. From the perspectiveof the patient, OWLb considers the patient's stratification data andclinical score information from POLAR, along with a detailed examinationof the patient's order and protocols. Upon examination of the patientand order, OWLb determines the appropriate Therapeutic Pharmacy tohandle this order. From the perspective of the prescriber, OWLbconsiders the orders that are coming through the system and identifiesorders belonging to patients from the same prescriber. Upon identifyingthese orders, OWLb bundles them together to minimize the number ofcontacts (i.e., phone calls) that are made to the prescriber duringprotocol resolution. From the perspective of the end user (i.e., thePharmacist or Clerk), OWLb chooses the best person to handle thepatient's order based on a variety of considerations. The end user mayhave many different skills ranging from clerical to professional, ofwhich each user has a varying degree of ability. For example, one usermay be considered an expert in one skill, while another user may only bea novice. OWLb takes all of these factors into consideration todetermine the optimal person to handle a particular patient'sprescription order, giving an optimal assignment of work for each enduser. OWLb may receive a prescription, patient stratification andclinical score information from Prescription Receiving. OWLb reviews theinformation, based upon formulary and rule sets to select a therapeuticpharmacy (800) within the network of therapeutic pharmacies, and assignsthe prescription to a pharmacist (900) within the selected therapeuticpharmacy to send the prescription to resolve any pharmaceuticalprotocols and filling the prescription. From the perspective of theoverall environment, OWLb considers the current work load, schedule andproductivity rate to perform load balancing. OWLb routes work where theend user is under utilized and attempts to maintain an even distributionof assignments. OWLb considers all of this telemetry data to perform anoptimal assignment of a patient's order to an end user, which results inless contact with the prescriber, lower cost of prescription handling,and improved care.

In assigning tasks, workers are entities that are capable of performingwork. An additional component of each task assignment is a timeconstraint, which is some limitation on when the work must beperformed—generally a deadline, but might include additionalrestrictions, such as “only call Dr. Lerner between 3 pm and 5 pm”. Aschedule is the collection of all task assignments for all pending(created but not resolved) tasks. The scope of a schedule might be asingle worker, groups of workers, or even the universal schedule (allworkers at all pharmacies). A schedule is conforming if it complies withclient and regulatory constraints. A task represents a particularinstantiation of a general process. It is explicitly represented by aprocess definition, which specifies, among other things, the steps in aprocess (i.e., sub-processes), required resources, required participants(e.g., pharmacist, prescriber), and definitions of process state, namelypreconditions, run-constraints, and post conditions, which specify,respectively, what will be true before, during, and after a process isexecuted. A state is represented by a set of facts (conditions) thathold in that state of the world. An analogy can be made to functions ina software language, where there is a single definition of the functionexpressed in terms of abstract parameters, then multiple actualinstantiations (i.e., function calls) where the parameters are replacedby actual, specific instances. In this context, protocols will be thelevel of process we are concerned with, tasks will be specific instancesof protocols, dealing with a particular work order, assigned toparticular workers (e.g., pharmacists). This architecture can handletasks assigned to machines, software applications, or human workers,though the focus here is on tasks that will be handled by a person. Bothtasks and workers can represent single entities, or collections ofentities, or collections of other collections. On the task side, themost primitive, indivisible unit of work is called a Work Item.Generally, a work item will be to attempt to resolve a single alert byfollowing its specified protocol. A task that is composed of other tasksis called a ‘composite task’, or ‘work bundle’. There are many possibleflavors of work bundle, depending on what the subtasks of a bundle havein common. For example, a ‘contact bundle’ is a collection of tasks thatcan be performed during a single contact with a prescriber. An ‘orderbundle’ is the collection of all tasks for a single order. Essentially,a bundle is a collection of tasks that can be treated as if it were asingle, atomic work item. OWL comprises primary components of acontroller, an estimator, monitors, seeker, and an optimizer. Thecontroller is the central manager, orchestrating the use of the othercomponents. Monitors receive event notifications from the rest of thesystem (e.g., work completed, worker calls in sick, etc.) and providethis information to the other scheduling components, such as “how manytasks are currently pending throughout all pharmacies and how does thatdiffer from X minutes ago.” The estimator is the ultimate judge as towhich schedule is best, by computing estimates of how long it will taketo complete a schedule, how many resources will be required, and thevalue of completing the work (costs and benefits), ultimately producinga utility score, in dollars, that represents the total value of acandidate schedule. The optimizer module is responsible for implementingan optimization strategy that utilizes the seeker component to generatenew candidate schedules and the estimator to decide which candidate isbest. The role of seeker is to make recommendations to the optimizer onhow to assign new work and to propose changes to existing schedules. Theoverall process will roughly go as follows. There will always be thecurrently executing schedule, managed by the controller, consisting ofthe universe of all work bins, each containing the set of tasks assignedto that bin. Simultaneously, the optimizer will be carrying out aparticular, configurable optimization strategy, attempting to constructnew schedules that are better than, and will eventually replace, thecurrent schedule. Periodically, the optimizer will notify the controllerthat it has created a superior schedule, at which point, if thecontroller accepts the new schedule, work items (tasks) will be placedor moved to implement the task assignments of the new schedule. Theworkflow component is not responsible for making decisions on who, when,or what work to do. Instead, the workflow component is responsible forcarrying out the managing of that work. The workflow component willreceive a message with the following three pieces of data: a) work thatneeds to be performed; b) who is assigned to perform that work; and c)when the work should be carried out. Upon receipt, the workflowcomponent will associate the given work with the given user, manage thework (for example carry out the schedule and authorization of work), andprovide Enterprise Application Integration (EAI) capabilities as definedin a configurable business process model (i.e., execution plan). Whenassociating work with the user, the workflow component will take asinput the work item and associate it with the provided user. Once theuser is associated with the work item, the workflow component isresponsible for ensuring the necessary security mechanisms are enforcedso that only the associate user can acquire, view, update, delete, andreassign the work. Managing the work includes all of the basicauthorization issues related to ensuring only the authorized user canaccess the associated work item. Managing the work also extends to ideaof carrying out a schedule; meaning that if the authorized user does notresolve the work in a particular amount of time, the workflow componentwill send a message back to one of OWLb's services indicating that thework is not yet resolved. This OWLb service will then determine the samethree identifiers as before (what, who, when) and instruct the workflowcomponent to manage the updated work. OWLb will read this plan in orderto orchestrate the communication between its optimizer and seekers. Thiswill provide a configurable means to define how the schedule will beimproved upon. For example, the schedule may be flowed from one seekerto the next, allowing each to improve upon the previous schedule and theoptimizer just selects the last schedule. An alternative plan would besuch that each seeker returns a single-schedule and the optimizerselects the best. In either case, the workflow engine will provide aconfigurable plan to allow such orchestrations of services. FIG. 6illustrates the work routed according to the invention, wherein thenumbers below the bars represent the number of prescriptions routed toparticular pharmacies. FIG. 7 illustrates the workload at a particularpharmacy segmented into various disease categories as well as a chart ofclinical score opportunities.

Therapeutic Pharmacy (800)

The network of therapeutic pharmacies of the invention may contain aplurality of individual therapeutic pharmacies, wherein the individualpharmacies are established to fill and dispense medications based on oneor more wellness categories or diseases. Generally, there may beindividual pharmacies for each of neurology/psychiatry, pulmonary,cardiovascular, diabetes, gastroenterology, oncology/hematology, rarediseases, etc. FIG. 4 illustrates two (2) such individual pharmacieswithin a network of comprising a plurality of individual pharmacies.Depending upon the classification of the patient into one or morecategories, OWLb will route the prescription to the specific pharmacywithin the network established to handle the prescription. Theindividual pharmacies will generally stock all of the medicationsassociated with particular diseases. After the prescription is filled,it may be forwarded to the patient by any one of numerous conventionalmeans, e.g., mail delivery, courier delivery, customer pick-up, etc. Theestablishment of individual therapeutic pharmacies within a network ofpharmacies will provide improved efficiency in resolving protocol,discussing specific issues with prescription writers and patients, andfilling and dispensing medications.

Therapeutic Pharmacist (900)

Within each individual pharmacy of the network of therapeutic pharmacieswill be a plurality of pharmacist specifically trained to resolveprotocol, discuss alternative medications with physicians and patientsfor the wellness state or disease classification of that individualpharmacy. A specially trained pharmacist, i.e., a pharmacist that seessimilar prescriptions for similar diseases and wellness states on aregular basis will be more familiar with patient conditions andalternative medications within a particular class of medications ofspecific diseases than a pharmacist operating with a general pharmacythat provides medications for all possible disease categories.

Integrated Contact Management (ICM) (1000)

Integrated Contact Management (ICM) is responsible for providing aone-stop solution to our Pharmacists in resolving protocols associatedwith a patient's order. ICM receives work from OWLb as determined to beoptimal for the current user of ICM. Upon receiving of the optimal work,Integrated Contact Management provides an integrated view of the patientinformation (stratification and clinical scoring), along withprescriber, client, and previous contact information to provide theend-user a complete picture of the patient and prescriber. Thepharmacist establishes communication with the prescriber and uses ICM toresolve all open protocols and adjudicate the patient's order. OWLb mayhave also bundled many orders together, in which case the end user willattempt to adjudicate the remaining orders in the bundle while theprescriber is on the telephone. Essentially, ICM monitors and managesthe time and work load of each individual therapeutic pharmacy as wellas each pharmacist within the individual pharmacy. ICM is suitable forinterfacing with physicians and health insurers to resolve any protocolissues with a prescription. ICM Summary Display is created and madeavailable directly in the Alpha ICM screen in the Alpha ProtocolResolution application and the ICM Viewer application. A link to accessmainframe Managed Care financial detail and processing screens isavailable directly in the Alpha ICM screen in the Alpha ProtocolResolution application and the ICM Viewer application. A patient detaildisplay is available one click away from the ICM screen in the AlphaProtocol Resolution application and the ICM Viewer application. MemberDetail Display is Clinical Opportunity Detail. New protocols may begenerated on all complex orders, one for financial opportunities, onefor clinical opportunities, and protocol resolution is used to trackopportunity outcomes and metrics. FIGS. 8 and 9 illustrates a typicalsystem print for a patient's unresolved protocols, wherein medicationsand correspondences, received and targeted delivery dates are shown.

1. A method comprising: receiving a pharmaceutical prescriptionassociated with a patient; accessing, on a processor, a medical recordand a plurality of prescription claims for the patient; analyzing, onthe processor, the medical record and the plurality of prescriptionclaims to classify the patient with a disease category; storing, on theprocessor, a patient clinical score based on at least a portion of theplurality of prescription claims, the medical record, formularyinformation, patient health insurance information, and an indication ofrisk for the patient taking a medication associated with thepharmaceutical prescription; and routing, on the processor, thepharmaceutical prescription to a therapeutic pharmacy among a network oftherapeutic pharmacies based on classification of the patient with thedisease category and the patient clinical score, each therapeuticpharmacy within the network of therapeutic pharmacies being establishedin accordance with a particular disease category.
 2. The methodaccording to claim 1, wherein the network of therapeutic pharmaciesincludes individual pharmacies for neurology, psychiatry, pulmonary,cardiovascular, diabetes, gastroenterology, oncology, hematology, rarediseases, and combinations thereof.
 3. The method of claim 1, furthercomprising: filling and dispensing the pharmaceutical prescription atthe therapeutic pharmacy.
 4. The method of claim 1, further comprising:assigning the pharmaceutical prescription to a pharmacist among aplurality of pharmacists in the therapeutic pharmacy based on skill,ability, or the skill and the ability of the pharmacist.
 5. The methodof claim 4, wherein assignment of the pharmaceutical prescription isfurther based on load balancing, the load balancing being based oncurrent work load, schedule, productivity rate of the plurality ofpharmacists, or combinations thereof.
 6. The method of claim 1, whereinthe patient clinical score reflects a relative level of possibility forthe patient to utilize a less costly medication than the medicationassociated with the pharmaceutical prescription.
 7. The method of claim1, wherein the medical record and the plurality of prescription claimsare further analyzed to stratify the patient into a wellness category,and wherein the routing of the pharmaceutical prescription is based onthe disease category, the wellness category, and the patient clinicalscore.
 8. The method of claim 1, further comprising: analyzing at leastsome of the plurality of prescription claims of the patient to determinea number of unique drugs obtained by the patient; analyzing at leastsome of the plurality of prescription claims of the patient to identifyconcurrent drug utilization review (CDUR) alert protocols that have aspecific resolution code; analyzing at least some of the plurality ofprescription claims of the patient to identify listed therapyoptimization and omission of therapy rules that have triggered an alert;analyzing at least some of the plurality of prescription claims of thepatient to determine whether the patient is late with prescriptionrefilling; and providing the indication of risk based on a determinationof the number of unique drugs obtained by the patient, an identificationof the CDUR alert protocols that have a specific resolution code, anidentification of the listed therapy optimization and omission oftherapy rules that have triggered an alert, and a determination that thepatient is late with prescription refilling.
 9. The method of claim 1,wherein analysis of the medical record and the plurality of prescriptionclaims includes identifying a concurrent drug utilization review alertprotocol that has a resolution code and generating a patient clinicalscore includes using the identified concurrent drug utilization reviewalert protocol to determine the patient clinical score.
 10. A methodcomprising: receiving a pharmaceutical prescription associated with apatient; accessing, on a processor, a medical record and a plurality ofprescription claims for the patient; storing, on the processor, aclassification of the patient into a disease category, theclassification based on analysis of the medical record and the pluralityof prescription claims; generating, on the processor, a patient clinicalscore based on the plurality of prescription claims, the medical record,formulary information, patient health insurance information, and anindication of risk for the patient taking a medication associated withthe pharmaceutical prescription; and routing, on the processor, thepharmaceutical prescription to a therapeutic pharmacy among a network oftherapeutic pharmacies based on the classification and the patientclinical score, each therapeutic pharmacy within the network oftherapeutic pharmacies being established in accordance with a particulardisease category.
 11. The method of claim 1, further comprising:generating and transmitting a message based on routing of thepharmaceutical prescription.
 12. The method of claim 1, wherein thetherapeutic pharmacy is a dispensing therapeutic pharmacy.
 13. Themethod of claim 1, wherein routing the pharmaceutical prescription tothe therapeutic pharmacy is based on the disease category, the patientclinical score, and load balancing, the load balancing being based oncurrent work load, schedule, and productivity rate.
 14. The method ofclaim 1, wherein the patient clinical score reflects a relative level ofcompliance by the patient with the medication associated with thepharmaceutical prescription.
 15. The method of claim 1, wherein themedical record and the plurality of prescription claims are furtheranalyzed to stratify the patient into a wellness category, and whereinthe routing of the pharmaceutical prescription is based on the diseasecategory, the wellness category, and the patient clinical score.
 16. Themethod of claim 15, wherein the wellness category is based on a diseasestate, the disease state being based on a medical category.
 17. Anon-transitory machine-readable medium comprising instructions, whichwhen executed by one or more processors, cause the one or moreprocessors to perform the following operations: receive a pharmaceuticalprescription associated with a patient; access a medical record and aplurality of prescription claims for the patient; analyze the medicalrecord and the plurality of prescription claims to classify the patientwith a disease category; store a patient clinical score based on atleast a portion of the plurality of prescription claims, the medicalrecord, formulary information, patient health insurance information, andan indication of risk for the patient taking a medication associatedwith the pharmaceutical prescription; and route the pharmaceuticalprescription to a therapeutic pharmacy among a network of therapeuticpharmacies based on classification of the patient with the diseasecategory and the patient clinical score, each therapeutic pharmacywithin the network of therapeutic pharmacies being established inaccordance with a particular disease category.
 18. A non-transitorymachine-readable medium comprising instructions, which when executed byone or more processors, cause the one or more processors to perform thefollowing operations: receive a pharmaceutical prescription associatedwith a patient; access a medical record and a plurality of prescriptionclaims for the patient; store a classification of the patient into adisease category, the classification based on analysis of the medicalrecord and the plurality of prescription claims; generate a patientclinical score based on the plurality of prescription claims, themedical record, formulary information, patient health insuranceinformation, and an indication of risk for the patient taking amedication associated with the pharmaceutical prescription; and routethe pharmaceutical prescription to a therapeutic pharmacy among anetwork of therapeutic pharmacies based on the classification and thepatient clinical score, each therapeutic pharmacy within the network oftherapeutic pharmacies being established in accordance with a particulardisease category.